Surgery for pseudoaneurysm of the ascending aorta under moderate hypothermia

Thoracic aortic pseudoaneurysm is a very rare complication after cardiac surgery with an incidence of less than 0.5% [1]. It has been reported that leaking at an aortic cannulation site is the major risk factor of pseudoaneurysm [2], and deep sternal infection or an increased possibility of suture dehiscence, such as after an ascending aortic dissection, showed the high occurrence of pseudoaneurysm [3]. A simple chest PA can detect widening of the mediastinum if the pseudoaneurysm is large and the diagnosis can be confirmed with chest CT and an echocardiogram.A 69 years old female patient was hospitalized for dyspnea, which was her chief complaint. The echocardiogram during the visit showed severe mitral stenosis (MVA = 0.8 cm2) and aortic stenosis (AVA = 0.7 cm2). Mild pulmonary hypertension (RVSP = 34 mmHg) and grade I tricuspid regurgitation were also present with a left ventricular ejection fraction of 43%. Left ventricular hypertrophy was present and the left ventricular wall motion was generalized hypokinetic, but no localized wall motion abnormality was found. According to the coronary artery angiogram, there was no stenosis of the coronary artery and the patient had no other significant medical history except for treatment for hypertension.During the surgery, the aortic valve and mitral valve were replaced with Hancock？ II (Medtronic) 23 mm and Hancock II (Medtronic) 27 mm, respectively, and then no postoperative complications were observed.On the 8th postoperative day, sternal infection was noted and pseudomonas aeruginosa was cultured on the culture test. The patient experienced only mild fever, so wound care and ceftazidime IV were concurrently administered. Curettage and debridement of the infected sternum were scheduled and we continued observing the patient. On the 11th postoperative day, there was massive bleeding at the retrosternal area, so an emergency operation was performed. The bleeding site was around the aortic vent insertion site and the aort